Category Archives: Patient safety and outcomes
Improvements to Dermatology Curriculum and Residency Training Could Improve Patient Safety, Study Finds
Modifications to curricula, systems, and teacher development may be needed to bring down medical error rates among dermatology residents, according to a study published online by JAMA Dermatology.
The survey of 142 dermatology residents from 44 residency programs in the United States and Canada draws attention to several areas of concern. According to the survey:
- Just over 45 percent of the residents failed to report needle-stick injuries incurred during procedures;
- Nearly 83 percent reported cutting and pasting a previous author’s patient history information into a medical record without confirming its validity;
- Nearly 97 percent reported right-left body part mislabeling during examination or biopsy; and
- More than 29 percent reported not incorporating clinical photographs of lesions sampled for biopsy in the medical records at their institutions.
Also, nearly three in five residents reported working with at least one attending physician who intimidates them, reducing the likelihood of reporting safety issues. More than three-quarters of residents (78 percent) have witnessed attending physicians ignoring required safety steps.
Improved patient safety and educational environments at academic medical centers were the goals of work-hour reforms adopted for first-year residents in 2011. A study published online by the Journal of Hospital Medicine shows that progress on the patient-safety front has been slow going.
Researchers examined data on patients discharged from the Johns Hopkins Hospital in Baltimore from 2008 to 2012 and analyzed safety outcomes for those seen by resident and non-resident hospitalists. The analysis revealed no significant differences—before and after the 2011 reforms that reduced the maximum length of residents’ on-duty shifts from 30 hours to 16—in areas including length of stay, 30-day readmission, inpatient mortality, ICU admission, and hospital-acquired-conditions.
The study concludes that, as noted by the Institute of Medicine, improving patient safety requires a significant focus on keeping residents’ caseloads manageable, ensuring adequate supervision of first-year residents, training residents on safe handoffs in care, and conducting ongoing evaluations of patient safety and any unintended consequences of work-hour reforms.
What drives “decision regret,” the negative cognitive emotion that occurs when an actual outcome differs from the desired or expected outcome? For nurses, fatigue is a big factor, according to a study in the current issue of the American Journal of Critical Care.
The study found that nurses impaired by fatigue, loss of sleep, daytime sleepiness, and an inability to recover between shifts are more likely than well-rested nurses to report decision regret. And while decision regret reflects previous decisions and adverse outcomes, it may also contribute to work-related stress and compromise patient safety in the future, the researchers found.
“Registered nurses play a pivotal role as members of the health care team,” lead author Linda D. Scott, RN, PhD, NEA-BC, FAAN, associate dean for academic affairs and an associate professor at the University of Illinois at Chicago College of Nursing, said in a news release. “Proactive intervention is required to ensure that critical care nurses are fit for duty and can make decisions that are critical for patients’ safety.”
Karen A. Daley, PhD, RN, FAAN, is president of the American Nurses Association. This post kicks off the “Health Care in 2014” series, in which health leaders, as well as Robert Wood Johnson Foundation scholars, grantees, and alumni share their New Year’s resolutions for our health care system and their priorities for action this year.
With so much attention focused these days on our health care system, it may not have occurred to you that the health of your own caregivers could also help determine the quality and safety of the care you receive.
Paying attention to things like getting enough rest, managing fatigue and work/life stress, living tobacco-free, taking advantage of preventive immunizations and exams, eating nutritionally and maintaining an active lifestyle and healthy weight are important for everyone. Unfortunately, nurses are often so busy caring for others that they fail to care for themselves. It is for this reason the American Nurses Association, which represents the interests of the nation's 3.1 million registered nurses (RNs), recently launched a Healthy Nurse™ program to promote healthier lifestyles and behaviors among nurses.
SreyRam Kuy, MD, MHS, is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, and a vascular surgery fellow at the Medical College of Wisconsin.
Gallbladder disease, and specifically gallstones, can present as pain in the upper abdomen, usually after eating fatty foods. More severely, gallstones can progress to an inflammation and infection called cholecystitis or cholangitis, both of which require prompt surgical treatment. Gallbladder disease is an important medical problem as it accounts for $650 billion in health care costs annually in the United States[i], making it the second most costly digestive disease in the country.[ii] With more than 700,000 cholecystectomies (surgeries to remove the gallbladder) performed annually in the United States, gallbladder disease is the number one reason for abdominal surgery in the nation.[i] Cholecystectomies can be done with traditional surgery (open cholecystectomy) or performed minimally invasively (laparoscopic cholecystectomy).
The National Health and Nutrition Examination Survey estimates 6.3 million men and 14.2 million women in the United States have gallbladder disease.[iii] It occurs two times more frequently in women than in men.[i][iv] However, during the reproductive years, women have a four-fold higher prevalence of gallstones than men.[iii] As a result of its disproportionate burden on women, gallbladder disease is a critically important topic in women’s health.
There is currently a lack of consensus on whether a patient’s gender affects how soon they get surgery for cholecystitis, what type of surgery they get (open versus laparoscopic cholecystectomy), and how they do after surgery. My prior work and that of my colleagues has clearly shown that older age negatively impacts how patients do following cholecystectomy.[v] Therefore, to determine whether gender, independent of other factors, affects outcome, we examined a national group of patients hospitalized with cholecystitis over an eight-year period, age-matched to account for the effect of age, and identified gender-based differences in patients hospitalized with cholecystitis. We measured outcomes of women compared with men who underwent cholecystectomy during that admission for cholecystitis, and identified factors associated with outcome.
Promoting Rigorous Interdisciplinary Research and Building an Evidence Base to Inform Health Care Learning, Practice, and Policy
By Mary D. Naylor, PhD, RN, FAAN, Marian S. Ware Professor in Gerontology, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, and co-director of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative. This commentary originally appeared on the Institute of Medicine website.
The Institute of Medicine (IOM) established the Roundtable on Value & Science-Driven Health Care to accelerate the advancement and application of science to achieve the best possible health and health care outcomes and value for Americans. The work of the roundtable is predicated on the notion that our health care system must continuously learn from rigorous evidence in order to innovate and improve. To that end, it acknowledges and promotes the importance of identifying best practices in health and health care, developing and testing innovations, and—most importantly— promoting collaborative efforts.
This vision for improving health and health care is shared by the Robert Wood Johnson Foundation, which funds an innovative and unique initiative to improve patient care by examining the role nurses play in improving care quality: the Interdisciplinary Nursing Quality Research Initiative (INQRI). Mark Pauly of the University of Pennsylvania and I have had the great privilege of serving as co-directors of this program since its inception in 2005.
This is part of the August 2013 issue of Sharing Nursing's Knowledge.
Nurse Manager Turnover Associated with Poorer Patient Outcomes
High turnover among hospital nurse managers can have negative effects on patient outcomes, according to a new study by a group of scholars that includes Robert Wood Johnson Foundation Executive Nurse Fellows alumna Karen Stefaniak, PhD, RN.
Stefaniak and colleagues used 27 months of data from 23 critical care and medical/surgical nursing units in two U.S. hospitals. Of the 23 nursing units in the study, 13 experienced "interim nurse management" during the period of the study, meaning that a nurse manager had recently left and an acting nurse manager was fulfilling his or her duties. Ten of the units had stable management. The data also included information on patient fall rates and pressure ulcer rates; these items were studied because they were deemed to be particularly "nurse-sensitive" indicators.
The results favored nursing units with stable management. Patients in medical/surgical units with nurse manager turnover were more likely to suffer falls, and patients in intensive care units with turnover were more likely to have pressure ulcers.
The authors conclude that nurse manager turnover "may negatively impact patient outcomes." They write: "One reason for this may be because nurse managers enable the flow of information between the broader organization and their patient care areas. When practice changes are made, nurse managers are often the primary conduit to ensure that their staffs are aware of and comply with the practice change. Equally important, when nursing staff develop innovative process improvements, nurse managers often facilitate the spread of the innovation from the nursing unit out to the broader organization."
This is part of the July 2013 issue of Sharing Nursing's Knowledge.
NP-Doctor Co-Management of Geriatric Cases Leads to Improved Outcomes
New research finds that geriatric patients with chronic conditions may have better outcomes if their cases are co-managed by a nurse practitioner (NP) and a physician than by a physician alone.
David Reuben, MD, chief of the Geriatrics Division in the Department of Medicine at the David Geffen School of Medicine at the University of California, Los Angeles, reports on the research leading to that conclusion in the June 2013 issue of the Journal of the American Geriatrics Society. Reuben and colleagues studied the cases of 485 patients who had one of four chronic conditions: falls; urinary incontinence (UI); dementia/Alzheimer's disease; or depression. Some of their cases were managed by doctors alone, and others were co-managed by doctors and NPs.
The researchers then examined individual patients' charts, assessing the quality of their care using several specific quality indicators. They found that patients whose cases were co-managed generally had better care, and significantly better care for some conditions. "Quality scores for all conditions (falls, 80 percent vs. 34 percent; UI, 66 percent vs. 19 percent; dementia, 59 percent vs. 38 percent) except depression (63 percent vs. 60 percent) were higher for individuals who saw a NP," they wrote.
Tracey L. Yap, PhD, RN, CNE, WCC, is an assistant professor at the Duke University School of Nursing, a John A. Hartford Foundation Claire M. Fagin Fellow, and a senior fellow at the Duke University Center for Aging and Human Development. With funding from the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI), Yap and her co-investigators developed a cost-effective, nurse-led intervention that aimed to reduce the prevalence of pressure ulcers in long-term care facilities by increasing resident mobility through a musical prompting system specifically tailored to each facility. This is part of a series of posts for National Nurses Week, highlighting how nurses are driving quality and innovation in patient care.
It started with a boombox and the Byrds.
Those are hardly the first things that come to mind when you think about pressure ulcers, also referred to as bed sores—the wounds that are caused by continuous, unrelieved pressure on the skin and that often develop in people who have impaired mobility. Yet that’s just how my husband, a physician who has a large population of patients in long-term care, inspired this research by suggesting that I pursue a grant related to this serious issue.
At one long-term care facility, my husband had a maintenance person use a boombox over the public address system to play “Turn, Turn, Turn” at two-hour intervals. It was a creative, simple, and fun way to remind staff to move patients, and it appeared to be effective in preventing pressure ulcers.
We were in Kentucky at the time, and I was teaching at the University of Cincinnati College of Nursing. When I took my husband’s suggestion and applied for an INQRI grant, it radically changed my life—and the lives of many long-term care residents—for good. In my PhD studies, I’d focused on occupational health, and the INQRI grant helped me apply that knowledge in a new way and ultimately led to my current work at Duke University.
This is part of the April 2013 issue of Sharing Nursing's Knowledge.
Survey of Nurses: Hospitals’ Patient Safety Programs Lacking
A new survey of hospital nurses in the United States, the United Kingdom, and China finds that nurses lack confidence in their hospitals’ safety programs.
The online survey, conducted by a research firm for the American Nurses Association (ANA) and GE Healthcare, included 500 respondents from the United States and 200 each from the United Kingdom and China. Each country's responses were given equal weight in the final results. Among the findings:
- Ninety-four percent of nurses report that their hospitals have programs in place that promote patient safety, but only 57 percent believe those programs are effective.
- Just 41 percent describe their hospital as “safe.”
- Ninety percent of nurses believe it is important that nurses not be penalized for reporting errors or near misses, but 59 percent agree that nurses often hold back in reporting patient errors in fear of punishment (67 percent in the United States, 62 percent in the United Kingdom, and 49 percent in China). Sixty-two percent agree that nurses often hold back in reporting near misses for the same reason (69 percent in the United States, 65 percent in the United Kingdom, and 54 percent in China).
- Thirty-three percent of nurses said that "poor communication among nurses at handoff" has increased the risk of patient safety incidents in their hospitals in the past 12 months. Thirty-one percent said "poor communication with doctors" has also increased the risk of patient safety incidents.